Atypical Ulcerations of the Penis
A 73-year-old man presented with a 3-month history of painful ulcers of the penis. He had a history of urinary incontinence after undergoing surgery for prostate cancer 6 years earlier; his cancer was being treated with diethylstilbestrol. The patient's general practitioner had prescribed valacyclovir, then amoxicillin, for treatment of the ulcers, without improvement. Physical examination showed ulcers filled with hard, fibrinous deposits around the external urethral orifice (Panel A) and on the foreskin (Panel B). The patient had no systemic symptoms. Laboratory studies were negative for human immunodeficiency virus and syphilis, and cultures were negative for herpes simplex virus and cytomegalovirus. Histopathological examination revealed epidermal necrosis, without evidence of viral inclusions, vasculitis, or atypical cell proliferation. On further questioning, the patient revealed that he had been using a diluted sodium hypochlorite lotion several times per day for cleaning his genitals. Sodium hypochlorite is a type of bleach that is used occasionally as a topical antimicrobial agent, typically to prevent skin or wound infection. It may cause mucosal necrosis when used improperly in endodontics. The lesions resolved 8 weeks after the patient stopped using sodium hypochlorite, and there have been no recurrences.